International Urogynecology Journal

, Volume 25, Issue 10, pp 1389–1398 | Cite as

Do women notice the impact of childbirth-related levator trauma on pelvic floor and sexual function? Results of an observational ultrasound study

  • Stéphanie Thibault-GagnonEmail author
  • Sara Yusuf
  • Suzanne Langer
  • Vivien Wong
  • Ka Lai Shek
  • Andrew Martin
  • Hans Peter Dietz
Original Article


Introduction and hypothesis

The levator ani is thought to play an important role in sexual function; however, to date little literature has been published on the impact of delivery–related levator trauma on female sexual function. We hypothesised that delivery-related levator trauma has a negative impact on women’s reports of pelvic floor and sexual function postpartum.


In 294 primigravid women with a singleton pregnancy, four-dimensional (4D) translabial ultrasound imaging was used to assess delivery–related levator avulsion and levator hiatal over-distension, and postpartum pelvic floor and sexual function was assessed by an in-house validated questionnaire. Associations between questionnaire responses and levator avulsion and hiatal over-distension were investigated using standard linear modelling methods.


Levator avulsion was diagnosed in 14 % of women (42 out of 292; 25 unilateral, 17 bilateral) and was found to be significantly associated with lower scores for the pelvic floor integrity and function domain of the questionnaire (P < 0.0005). Avulsion was associated with lower scores for this domain (no avulsion = 2.78, unilateral avulsion = 2.61, bilateral avulsion = 2.29). This association remained significant after controlling for potential confounders (p = 0.013). Avulsion was not associated with any of the other domains of sexual function and levator hiatal over-distension was not associated with scores for any of the questionnaire domains.


The effect of levator avulsion on pelvic floor and sexual function an average of 5.2 months after childbirth seems to be limited to a perception of increased vaginal and pelvic floor muscle laxity, and reduced pelvic floor muscle efficiency. The impact of levator hiatal over-distension on postpartum pelvic floor and sexual function appears to be negligible.


Avulsion Childbirth Levator trauma Pelvic floor muscle function Primiparas Sexual function 



We would like to acknowledge the help of Suzanne Abraham, Associate Professor in Obstetrics & Gynaecology, University of Sydney, with the design of early versions of this questionnaire. Stephanie Thibault-Gagnon received scholarship support from the Natural Sciences and Engineering Research Council of Canada.


OZWAC (Australian Women and Children’s Research Foundation).

Conflicts of interest

Prof H.P. Dietz has received unrestricted educational grants from GE Medical. The other authors have no potential conflicts of interest to declare.

Supplementary material

192_2014_2331_MOESM1_ESM.pdf (310 kb)
ESM 1 (PDF 310 kb)


  1. 1.
    Krofta L, Otcenasek M, Kasikova E, Feyereisl J (2009) Pubococcygeus-puborectalis trauma after forceps delivery: evaluation of the levator ani muscle with 3D/4D ultrasound. Int Urogynecol J 20(10):1175–1181. doi: 10.1007/s00192-009-0837-6 CrossRefGoogle Scholar
  2. 2.
    Albrich SB, Laterza RM, Skala C, Salvatore S, Koelbl H, Naumann G (2012) Impact of mode of delivery on levator morphology: a prospective observational study with three-dimensional ultrasound early in the postpartum period. BJOG 119(1):51–60. doi: 10.1111/j.1471-0528.2011.03152.x PubMedCrossRefGoogle Scholar
  3. 3.
    Shek KL, Dietz HP (2010) Intrapartum risk factors for levator trauma. BJOG 117(12):1485–1492. doi: 10.1111/j.1471-0528.2010.02704.x PubMedCrossRefGoogle Scholar
  4. 4.
    Dietz HP, Lanzarone F (2005) Levator trauma after vaginal delivery. Obstet Gynecol 106(4):707–712PubMedCrossRefGoogle Scholar
  5. 5.
    Shek KL, Dietz HP (2010) Can levator avulsion be predicted antenatally? Am J Obstet Gynecol 202(6):586.e1. doi: 10.1016/j.ajog.2009.11.038 CrossRefGoogle Scholar
  6. 6.
    Dietz HP, Shek C, De Leon J, Steensma AB (2008) Ballooning of the levator hiatus. Ultrasound Obstet Gynecol 31(6):676–680. doi: 10.1002/uog.5355 PubMedCrossRefGoogle Scholar
  7. 7.
    Dietz HP, Simpson JM (2008) Levator trauma is associated with pelvic organ prolapse. BJOG 115(8):979–984. doi: 10.1111/j.1471-0528.2008.01751.x PubMedCrossRefGoogle Scholar
  8. 8.
    Dietz HP, Chantarasorn V, Shek KL (2010) Levator avulsion is a risk factor for cystocele recurrence. Ultrasound Obstet Gynecol 36(1):76–80. doi: 10.1002/uog.7678 PubMedCrossRefGoogle Scholar
  9. 9.
    Model AN, Shek KL, Dietz HP (2010) Levator defects are associated with prolapse after pelvic floor surgery. Eur J Obstet Gynecol Reprod Biol 153(2):220–223. doi: 10.1016/j.ejogrb.2010.07.046 PubMedCrossRefGoogle Scholar
  10. 10.
    Dietz HP, Shek KL, Chantarasorn V, Langer SEM (2012) Do women notice the effect of childbirth-related pelvic floor trauma? Aust N Z J Obstet Gynaecol 52(3):277–281. doi: 10.1111/j.1479-828X.2012.01432.x PubMedCrossRefGoogle Scholar
  11. 11.
    Botelho S, Riccetto C, Herrmann V, Pereira LC, Amorim C, Palma P (2010) Impact of delivery mode on electromyographic activity of pelvic floor: comparative prospective study. Neurourol Urodyn 29(7):1258–1261. doi: 10.1002/nau.20864 PubMedCrossRefGoogle Scholar
  12. 12.
    Sigurdardottir T, Steingrimsdottir T, Arnason A, Bo K (2011) Pelvic floor muscle function before and after first childbirth. Int Urogynecol J 22(12):1497–1503. doi: 10.1007/s00192-011-1518-9 PubMedCrossRefGoogle Scholar
  13. 13.
    Dietz HP (2004) Levator function before and after childbirth. Aust N Z J Obstet Gynaecol 44(1):19–23PubMedCrossRefGoogle Scholar
  14. 14.
    Dietz HP, Shek C (2008) Levator avulsion and grading of pelvic floor muscle strength. Int Urogynecol J 19(5):633–636. doi: 10.1007/s00192-007-0491-9 CrossRefGoogle Scholar
  15. 15.
    Lowenstein L, Gruenwald I, Gartman I, Vardi Y (2010) Can stronger pelvic muscle floor improve sexual function? Int Urogynecol J 21(5):553–556.  10.1007/s00192-009-1077-5 PubMedCrossRefGoogle Scholar
  16. 16.
    Messe MR, Geer JH (1985) Voluntary vaginal musculature contractions as an enhancer of sexual arousal. Arch Sex Behav 14(1):13–28. doi: 10.1007/bf01541349 PubMedCrossRefGoogle Scholar
  17. 17.
    Shek KL, Chantarasorn V, Langer S, Phipps H, Dietz HP (2011) Does the Epi-NoA (R) Birth Trainer reduce levator trauma? A randomised controlled trial. Int Urogynecol J 22(12):1521–1528. doi: 10.1007/s00192-011-1517-x PubMedCrossRefGoogle Scholar
  18. 18.
    Dietz HP, Bernardo MJ, Kirby A, Shek KL (2011) Minimal criteria for the diagnosis of avulsion of the puborectalis muscle by tomographic ultrasound. Int Urogynecol J 22(6):699–704. doi: 10.1007/s00192-010-1329-4 PubMedCrossRefGoogle Scholar
  19. 19.
    Rosen R, Brown C, Heiman J, Leiblum S, Meston C, Shabsigh R, Ferguson D, D'Agostino R (2000) The Female Sexual Function Index (FSFI): a multidimensional self-report instrument for the assessment of female sexual function. J Sex Marital Ther 26(2):191–208. doi: 10.1080/009262300278597 PubMedCrossRefGoogle Scholar
  20. 20.
    Rogers GR, Villarreal A, Kammerer-Doak D, Qualls C (2001) Sexual function in women with and without urinary incontinence and/or pelvic organ prolapse. Int Urogynecol J Pelvic Floor Dysfunct 12(6):361–365. doi: 10.1007/s001920170012 PubMedCrossRefGoogle Scholar
  21. 21.
    Abdool Z, Shek KL, Dietz HP (2009) The effect of levator avulsion on hiatal dimension and function. Am J Obstet Gynecol 201(1):89.e1. doi: 10.1016/j.ajog.2009.02.005 CrossRefGoogle Scholar
  22. 22.
    Serati M, Salvatore S, Siesto G, Cattoni E, Zanirato M, Khullar V, Cromi A, Ghezzi F, Bolis P (2010) Female sexual function during pregnancy and after childbirth. J Sex Med 7(8):2782–2790. doi: 10.1111/j.1743-6109.2010.01893.x PubMedCrossRefGoogle Scholar
  23. 23.
    Lurie S, Aizenberg M, Sulema V, Boaz M, Kovo M, Golan A, Sadan O (2013) Sexual function after childbirth by the mode of delivery: a prospective study. Arch Gynecol Obstet 288(4):785–792. doi: 10.1007/s00404-013-2846-4 PubMedCrossRefGoogle Scholar
  24. 24.
    Hosseini L, Iran-Pour E, Safarinejad MR (2012) Sexual function of primiparous women after elective cesarean section and normal vaginal delivery. Urol J 9(2):498–504PubMedGoogle Scholar
  25. 25.
    Dean N, Wilson D, Herbison P, Glazener C, Aung T, Macarthur C (2008) Sexual function, delivery mode history, pelvic floor muscle exercises and incontinence: a cross-sectional study six years post-partum. Aust N Z J Obstet Gynaecol 48(3):302–311. doi: 10.1111/j.1479-828X.2008.00854.x PubMedCrossRefGoogle Scholar
  26. 26.
    Millheiser LS, Pauls RN, Herbst SJ, Chen BH (2010) Radiofrequency treatment of vaginal laxity after vaginal delivery: nonsurgical vaginal tightening. J Sex Med 7(9):3088–3095. doi: 10.1111/j.1743-6109.2010.01910.x PubMedCrossRefGoogle Scholar
  27. 27.
    Pauls RN, Fellner AN, Davila GW (2012) Vaginal laxity: a poorly understood quality of life problem; a survey of physician members of the International Urogynecological Association (IUGA). Int Urogynecol J 23(10):1435–1448. doi: 10.1007/s00192-012-1757-4 PubMedCrossRefGoogle Scholar
  28. 28.
    Goodman MP (2011) Female genital cosmetic and plastic surgery: a review. J Sex Med 8(6):1813–1825. doi: 10.1111/j.1743-6109.2011.02254.x PubMedCrossRefGoogle Scholar
  29. 29.
    Citak N, Cam C, Arslan H, Karateke A, Tug N, Ayaz R, Celik C (2010) Postpartum sexual function of women and the effects of early pelvic floor muscle exercises. Acta Obstet Gynecol Scand 89(6):817–822. doi: 10.3109/00016341003801623 PubMedCrossRefGoogle Scholar
  30. 30.
    Abdool Z, Thakar R, Sultan AH (2009) Postpartum female sexual function. Eur J Obstet Gynecol Reprod Biol 145(2):133–137. doi: 10.1016/j.ejogrb.2009.04.014 PubMedCrossRefGoogle Scholar

Copyright information

© The International Urogynecological Association 2014

Authors and Affiliations

  • Stéphanie Thibault-Gagnon
    • 1
    Email author
  • Sara Yusuf
    • 2
  • Suzanne Langer
    • 2
  • Vivien Wong
    • 2
  • Ka Lai Shek
    • 2
  • Andrew Martin
    • 3
  • Hans Peter Dietz
    • 2
  1. 1.School of Rehabilitation TherapyQueen’s UniversityKingstonCanada
  2. 2.Sydney Medical School NepeanPenrithAustralia
  3. 3.NHMRC Clinical Trials CentreUniversity of SydneySydneyAustralia

Personalised recommendations